Forms & Documents
Below you will find many of the forms and documents you may need. If you don't see a form or document you need on this page, please click here to contact us.Forms:
Change of Status Form: To change member information such as name, coverage election(s) or termination of coverage benefits. General Motors employees must contact the National Benefits Center at 1-(800) 489-4646. Forms must be signed by your employer prior to submission to MercyCare.
PHI Release Form: Use when a member would like MercyCare to provide personal health information (PHI) to a third party. Examples of this would be benefits available or claims information.
Stay Healthy Benefit Reimbursement Form: To request reimbursement for health and wellness activities.
ACH Form: To authorize MercyCare to take premiums due directly from a checking or savings account. This is limited to members who pay premiums directly to MercyCare.
Drug Reimbursement Form*: Use this form to request reimbursement of monies paid directly by you for prescription drugs. Applicable coverage for co-insurance and/or co-pays will be deducted from reimbursement.
*Not all members recieve their Drug Plan benefits through MercyCare. If you are unsure, and would like to verify your prescription drug benefits, please contact your employer or MercyCare's Customer Service at 1-(800) 895-2421.
Janesville Athletic Club membership benefits
Rock County YMCA membership benefits